Training for bronchoscopists: is less more?

terventional pulmonology’. The real challenge has been the rapid and widespread uptake of endobronchial ultrasound procedures. This procedure requires different skill sets, such as standard bronchoscopy, and success is based on the knowledge of the extrabronchial vasculature and bronchial and lymph node anatomy. Subtle differences are bronchoscope handling, for example the need to oppose the bronchoscope to the airway surface to obtain adequate ultrasound visualisation. For standard bronchoscopy, the standard teaching is still to avoid airway contact as this induces cough. The sampling process is also different from standard bronchoscopy. A study by Kemp et al. [9] demonstrated that different individuals acquire skills at different rates. In their study, the diagnostic outcomes for endobronchial ultrasound procedures performed by five different operators were evaluated for their first 100 procedures. It was evident that some individuals were competent in performing procedures very quickly, whereas others were still on their learning curve even after almost 100 procedures. Even though the operators in this study received no formal training and were early adopters of the technology, this study enforces the point that patients should not be exposed to risks and procedural failures due to individuals still in the training phase for these particular procedures. Whilst the apprenticeship model was the accepted method for skills training in the past, at present we agree that Over the past 10 years, the complexity of bronchoscopy has dramatically evolved. Standard bronchoscopy consists of visual inspection with possible sampling by bronchial lavage, bronchial biopsy or bronchial brushings. Tumour resection and stent insertion were the domain of the few interventional pulmonologists that performed rigid bronchoscopy or the thoracic surgeons. In the last 10 years, there has been an increase in interventional procedures that are safely and easily performed under local anaesthesia with flexible bronchoscopy: from diathermy, argon plasma photocoagulation, cryotherapy through to stent insertion [1] . Furthermore, there has been the introduction of a number of lung volume reduction procedures for emphysema performed by flexible bronchoscopy utilising endobronchial valves [2–4] or endobronchial coils [5] . Procedures like airway bypass – although performed by flexible bronchoscopy – are very complex and involve several different skills such as the identification of blood vessels with ultrasound, transbronchial needle insertion, balloon dilatation and stent insertion [6] . Other procedures such as bronchial thermoplasty for asthma, however, require a pragmatic systemic approach and good anatomical knowledge to ensure that all of the possible accessible airways are treated with radiofrequency energy [7, 8] . These procedures are still the domain of selected bronchoscopists who have developed the new speciality of ‘inPublished online: February 12, 2015